Is it safe to use intranasal steroids or Ryaltris (mometasone furoate and azelastine) in patients with paradoxical vocal cord dysfunction (PVCD)?

Intranasal Steroids and Ryaltris in Paradoxical Vocal Cord Dysfunction

Intranasal steroids and Ryaltris (mometasone furoate and azelastine) can be safely used in patients with paradoxical vocal cord dysfunction (PVCD), as there is no evidence suggesting these medications worsen PVCD symptoms or affect vocal cord function.

Understanding PVCD and Its Relationship to Upper Airway Treatments

PVCD is characterized by intermittent paradoxical adduction of the vocal cords, primarily during inspiration, leading to airflow obstruction and dyspnea 1. This condition can mimic or coexist with asthma, often leading to misdiagnosis and inappropriate treatment.

Key considerations for PVCD patients:

• PVCD is often triggered by postnasal drip, laryngopharyngeal reflux, or gastroesophageal reflux, which can lead to laryngeal hyperresponsiveness 1, 2
• The condition may be exacerbated by irritants, including inhaled substances 1
• Treatment typically involves speech therapy, breathing techniques, and addressing underlying conditions 3

Safety of Intranasal Steroids in PVCD

Intranasal corticosteroids are considered safe and effective for treating allergic rhinitis and related conditions:

• Intranasal steroids are recommended as first-line therapy for allergic rhinitis due to their efficacy and safety profile 4
• When used at recommended doses, intranasal corticosteroids are not generally associated with clinically significant systemic side effects 5
• Unlike oral steroids, intranasal formulations have minimal systemic absorption and primarily act locally 5

Ryaltris (Mometasone + Azelastine) Considerations

Ryaltris combines an intranasal steroid (mometasone furoate) with an antihistamine (azelastine):

• The combination of intranasal antihistamines and steroids can be effective for patients with inadequate response to monotherapy 4
• Both components act locally in the nasal passages with minimal systemic effects 4

Benefits of Treating Allergic Rhinitis in PVCD Patients

Treating allergic rhinitis or rhinosinusitis in PVCD patients may actually improve their condition:

• Postnasal drip is a known trigger for PVCD, and treating the underlying allergic rhinitis can reduce this trigger 1, 2
• Intranasal steroids effectively reduce nasal inflammation, congestion, and postnasal drip that may contribute to PVCD symptoms 4
• Controlling upper airway symptoms may reduce laryngeal irritation that can trigger PVCD episodes 2, 6

Practical Recommendations

1. Use intranasal steroids or Ryaltris as indicated for allergic rhinitis symptoms 4

2. Proper administration technique is important:

   • Direct sprays away from the nasal septum to minimize local side effects 5
   • Instruct patients on correct usage to maximize effectiveness 4

3. Monitor for any potential exacerbation of PVCD symptoms:

   • While not expected, individual responses may vary 1
   • If symptoms worsen, consider alternative treatments 2

4. Address PVCD directly with appropriate therapies:

   • Speech therapy and breathing techniques remain the cornerstone of PVCD treatment 3
   • Regular respiratory retraining therapy (every 3 months) has shown better outcomes than annual therapy 3

Cautions and Considerations

• Local side effects of intranasal steroids may include nasal irritation, epistaxis, and dryness, but these are generally mild and transient 4, 5
• Patients should be monitored periodically for nasal septal changes with long-term use 5
• PVCD is often misdiagnosed as asthma, leading to inappropriate treatment with systemic corticosteroids 7

In conclusion, intranasal steroids and Ryaltris can be safely used in patients with PVCD and may actually help improve PVCD symptoms by addressing underlying allergic rhinitis and reducing postnasal drip that can trigger PVCD episodes.